NCLEX NCLEX-PN
Kaplan NCLEX Question of The Day
1. After an escharotomy of the forearm, what is the priority nursing assessment for the client who has returned to your unit?
- A. Infection
- B. Incision
- C. Pain
- D. Tissue perfusion
Correct answer: D
Rationale: The correct answer is "Tissue perfusion." After an escharotomy, the priority assessment is to ensure adequate tissue perfusion to the affected limb. Escharotomy is performed to relieve circulatory compromise by cutting through the eschar, so monitoring tissue perfusion is crucial to assess the effectiveness of the procedure and prevent complications. Assessing for infection is important but comes after ensuring adequate tissue perfusion. Checking the incision is necessary but assessing tissue perfusion takes precedence. Pain assessment is important but not the priority compared to assessing tissue perfusion to prevent ischemic complications.
2. A young female teenager describes a brutal assault and rape to the nurse on duty. Which of the following actions should the nurse take first?
- A. Check with the case manager on duty about possible police intervention.
- B. Provide an environment of concern and emotional stabilization.
- C. Clean the patient’s wounds with normal saline and gauze.
- D. Refer the patient to a counselor specializing in trauma.
Correct answer: Provide an environment of concern and emotional stabilization.
Rationale: In a situation where a patient describes a brutal assault and rape, the first priority should be to provide emotional support and create a safe and supportive environment. This helps the patient feel secure and cared for, which is crucial for their well-being at that moment. Checking with the case manager about police intervention should come after ensuring the patient's immediate emotional needs are addressed. Cleaning the patient’s wounds, though important, can be secondary to providing emotional stabilization. Referring the patient to a counselor specializing in trauma is also crucial for long-term support, but the immediate focus should be on providing emotional support and stability.
3. A nurse is preparing to test the function of cranial nerve XI. Which action does the nurse take to test this nerve?
- A. Asking the client to stick out his or her tongue and watching for tremors
- B. Touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex
- C. Depressing the client’s tongue with a tongue blade and noting pharyngeal function as the client says 'ah'
- D. Placing his or her hands on the client’s shoulders and asking the client to shrug the shoulders against resistance from the nurse’s hands
Correct answer: Placing his or her hands on the client’s shoulders and asking the client to shrug the shoulders against resistance from the nurse’s hands
Rationale: To assess the function of cranial nerve XI (spinal accessory nerve), the nurse examines the sternomastoid and trapezius muscles for equal size and strength. The correct method involves asking the client to rotate the head forcibly against resistance to the side of the chin and to shrug the shoulders against resistance from the nurse’s hands. Choice A, asking the client to stick out the tongue and watching for tremors, is used to assess cranial nerve XII (hypoglossal nerve). Choice C, depressing the client’s tongue with a tongue blade and noting pharyngeal function as the client says 'ah', is the technique for examining cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve). Choice B, touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex, is used to evaluate cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve), not cranial nerve XI.
4. The client has been on vancomycin for three days. Which of the following symptoms is least concerning?
- A. nausea
- B. headache
- C. vertigo
- D. tinnitus
Correct answer: headache
Rationale: The correct answer is 'headache.' While vancomycin can cause ototoxicity leading to symptoms like tinnitus, vertigo, and nausea, headaches are not typically associated with vancomycin use. Therefore, headache is the least concerning symptom in this scenario. Nausea, vertigo, and tinnitus are more likely to be related to vancomycin ototoxicity and should be closely monitored and reported. Headache is a common symptom that may not be directly linked to vancomycin use.
5. Which of the following behaviors is least appropriate when dealing with fellow staff members?
- A. Provide positive feedback and constructive criticism
- B. Serve as a resource
- C. Only report conflicts that interfere with client care
- D. Provide input for performance evaluations
Correct answer: C: Only report conflicts that interfere with client care
Rationale: The least appropriate behavior when dealing with fellow staff members is to only report conflicts that interfere with client care. This choice implies ignoring or neglecting other conflicts that may affect team dynamics and the work environment. It is crucial to address and report all conflicts, whether they impact client care directly or not, to maintain a harmonious and effective working relationship within the healthcare setting. Providing positive feedback, constructive criticism, serving as a resource, and offering input for performance evaluations are all important and appropriate behaviors that contribute to a supportive and professional work environment. By focusing solely on conflicts that interfere with client care, essential issues that influence teamwork and overall staff morale may be overlooked, potentially leading to a negative impact on the work environment.
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